Healthcare systems in the US greatly rely on Managed Care organizations for management of costs, utilization, as well as quality of the organization by the use of comprehensive set of services. The managed care systems have significantly reduced the expenditure of healthcare systems on healthcare delivery in addition to improving patients’ access to specialized care. The alliance of the healthcare organizations and Managed Care Organization equally aim at eliminating and preventing fraud cases and abuse occurring in medical facilities. Managed Care Organizations are vital in ensuring risk management in healthcare facilities to ensure efficient performance and quality health service delivery.
What is a Health Care Organization’s Administrative Role in Executing Risk Management Policies and Ensuring Compliance with Managed Care Organization (MCO) Standards?
The administrative role of the healthcare organization towards risk management policies in order to ensure compliance with managed care organization standards entails formulation of policies and programs that involve stakeholder and the public in activities that are decision oriented (McGinnis, Houston, and Brown, 2013). The healthcare administration develops a comprehensive contract that contains the criteria used in selecting medical practitioners. The organization’s administrators must ensure that the facility is equipped with sufficient and competent staff as per the MCOs requirements (Medicaid CMS, 2002). In addition, for healthcare organizations to be provided with Medicaid health services, the administrators must ensure that they have enough clinics. Besides, according to Medicaid CMS (2002), the healthcare organizations are tasked with providing quality health services to all Medicaid enrollees.
What Value do the Regulatory Statutes of a Typical MCO provide to a Health Care Organization?
According to Butler (1996), one of the state regulation of Managed Care Organization include the incentive inherent in a constant payment capitation, which not only regulates the financial solvency but also the capacity to serve the Medicaid beneficiaries, as well as quality of care provided. With the implementation of the incentive inherent regulatory statute of a typical managed care organization, the healthcare organization can adequately provide quality medical services to its clients, in addition to maintaining good healthcare service records. Moreover, the healthcare staff members are not subjected to tedious working days, since the number of Medicaid beneficiaries are regulated per health facility, thus more job satisfaction and ultimately positive impact on patients’ care. Additionally, fraud and abuse cases are prevented with the implementation of the comprehensive compliance programs of the MCOs.
Consider how Strategies pertaining to Policies such as Conflict Resolution and Risk Management affect Patients as well as Employees and Employers.
Conflicts in healthcare organizations are bound to arise just as in other working environments. There are strategies like mediation used to resolve conflicts in the healthcare environment which improves the relationship among the employers, employees, and patients. Dubler (2002) argues that mediation eventually leads to consensus on care plans uniting medical teams, linking patients and families, and promoting communication between health providers and patients. Risk management strategies protect patients from receiving wrong medication or spending more on treatment. On the other hand, employers protect their image and are cushioned from losing funds through fraud or facing legal charges due to abuse.
What MCO responsibilities relevant to the Patient Protection and Affordable Care Act (ACA) and Center for Medicare and Medicaid Services (CMS) focus on fraud, waste, and abuse laws?
The Patient Protection and Affordable Care Act passed in 2010, is a healthcare legislation that covers fraud, waste, and abuse provisions to help the federal government in combating inappropriate payments in Medicaid, Medicare, and Children’s Health Insurance Program (Centre for Medicare Advocacy). According to the PPACA requirements, the managed care organizations are tasked with ensuring that no overpayments by the federal government are made to medical insurance companies like Medicare, implement penalties set for fraudsters, avail the name of the National Provider Identifier (NPI) of Medicare who was terminated from Medicare involvement within 30 days of termination (Centre of Medicare Advocacy) in order to prevent he or she from mismanaging the Medicare funds.
Butler, P. A. (1996). Medicare Managed Care: Protecting Consumers and Enhancing Satisfaction. NCBI. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK233033/
Centre for Medicare Advocacy. (n.d). Combating Fraud, Waste, and Abuse in Healthcare. Centre for Medicare Advocacy. Retrieved from https://www.medicareadvocacy.org/combating-fraud-waste-and-abuse-in-health-care/
Dubler, N. N. (2002). Mediating Disputes in Managed Care: Resolving Conflicts over Covered Services. Journal of Healthcare Law and Policy. Retrieved from https://core.ac.uk/download/pdf/56355331.pdf
McGinnis T., Houston, R. & Brown, D. (November 2013). The Balancing Act: Integrating Medicaid Accountable Care Organizations into a Managed Care Environment. Centre for Healthcare Strategies. Retrieved from https://www.chcs.org/media/ACO111313_Final.pdf
Medicaid CMS. (May 2002). Guidelines for Constructing A Compliance Program for Medicaid Managed Care Organizations and Prepaid Health Plans. Medicaid CMS. Retrieved fromhttps://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/FraudAbuseforProfs/Downloads/mccomplan.pdf